THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 14, Number 1, 2008, pp.

95102 Mary Ann Liebert, Inc. DOI: 10.1089/acm.2007.7170A

PARADIGMS

Challenges Inherent to Tai Chi Research: Part ITai Chi as a Complex Multicomponent Intervention
PETER M. WAYNE, Ph.D., and TED J. KAPTCHUK

ABSTRACT In this, the first of 2 companion papers, we present a framework for viewing tai chi as a complex, multicomponent intervention that integrates numerous physical, cognitive, and ritualistic components. We discuss how the richness and complexity of tai chi poses challenges related to the traditional distinction between specific versus nonspecific effects, the development and interpretation of valid sham controls, and more generally, to the reductionist causal approach of attributing observed outcomes to single, independent component factors. We also discuss parallels between tai chi research and the emerging field of whole systems research, and how tai chi research may benefit from the use of an ecologic framework. In a second, companion paper, we discuss additional challenges inherent in defining the tai chi intervention itself, and more comprehensively outline the benefits and limitations of commonly used clinical research designs to evaluate the efficacy and safety of tai chi.

INTRODUCTION

ai chi, also referred to as Taiji, Tai Chi Chuan, or Taijiquan, is a mindbody exercise that originated in China, and that is growing in popularity in the West. Recent surveys suggest that approximately 5 million Americans have practiced tai chi, and this number is increasing.1,2 Because tai chi is purported to be safe and effective, even for the elderly and frail, it has the potential to be widely integrated into health care. However, the extent of its integration and adoption by the health care community will depend to a large degree on research-based evidence regarding its efficacy and safety for different populations and for specific medical conditions. A growing body of clinical research has begun to evaluate the efficacy and safety of tai chi as a preventative and rehabilitative therapeutic tool for a variety of health issues including: balance and postural stability,312 musculoskeletal strength and flexibility,6,1315 cardiorespiratory fitOsher Institute, Harvard Medical School, Boston, MA.

ness1421 immune function,22,23 and general stress management.2426 This research has been summarized and critically evaluated in recent reviews.1232 However, little attention has been devoted to evaluating how tai chi is scientifically studied, and the advantages or limitations of different methodological approaches. Understanding the strength and weakness of each approach will increase the likelihood of a complete and unbiased understanding of the potential value of tai chi in health care. We begin this paper with a brief overview of the history and principles of tai chi and present a framework for viewing tai chi as a complex, multicomponent intervention that integrates numerous physical, cognitive, and ritualistic components. We discuss how the richness and complexity of tai chi poses challenges related to the traditional distinction between specific versus nonspecific effects, the development of valid (inert) sham controls, and more generally, to the reductionistic (causal) approach of attributing observed outcomes to single, independent, component factors. We con-

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96 clude with a discussion of the potential of whole systems (ecologic) approaches to studying tai chi. In a companion paper,33 we will discuss additional challenges inherent to the study of tai chi including tai chis pluralism, the concept of tai chi dosage, and long-term versus short-term evaluations of tai chis efficacy and safety, and outline the benefits and limitations of commonly employed clinical research methods.

WAYNE AND KAPTCHUK characterization of the complexity of tai chi intervention and the potential therapeutic effects on its practitioners is presented in Figure 1. This diagram summarizes tai chis therapeutic components into 8 broad classes. Below we briefly review the relevance of each of these components, citing, when available, evidence of its potential therapeutic value. This deconstruction of tai chi into separate components will help illustrate that tai chi is a complex intervention, and provide a framework for both better evaluating the advantages and disadvantages of various research methodologies and for interpreting results of studies to date.

TAI CHI: GENERAL BACKGROUND Definition and history

Tai Chi Chuan is commonly translated as Supreme (Grand) Ultimate Fist or Boxing, with Supreme Ultimate referring to the all-encompassing Taoist dialectical principle of Yin and Yang on which it is based.34,35 Tai chi is variously described as a meditative or internal martial art or a moving mindbody exercise. In this paper, we define tai chi as an exercise based on slow intentional movements, often coordinated with breathing and imagery, which aims to strengthen and relax the physical body and mind, enhance the natural flow of what the Chinese call qi (a nontranslatable word that describes the interpenetration and connection of phenomenon, or life energy), and improve health, personal development, and self-defense. The history of tai chi is not well understood. China has a long history of health-enhancement exercises that mimic animal movements, however, how these earlier exercises link to what we now call tai chi is unclear.35 The first written mention of Tai Chi Chuan is in a 17th-century text authored by the martial artist Chen Wangting where it is described as a new style of kung fu.35 Despite this explicit origin in the martial arts, tai chi as currently taught and practiced commonly integrates Traditional Chinese Medicine principles of health and longevity, meditative and spiritual principles, and Taoist philosophy into its training regimen.3640

Musculoskeletal strength, flexibility and efficiency

Perhaps the most obvious component of tai chi training is its emphasis of the musculoskeletal system. Phrases from historical tai chi classics such as suspend the spine like a string of pearls from heaven, and stand like a balance and move like a cartwheel,35 reflect inherent, sophisticated insight regarding human balance and movement. A large body of sound research supports that tai chi training can improve musculoskeletal strength and flexibility.6,1215 Research using sophisticated motion analysis has also demonstrated that tai chi alters a number of neuromuscular components associated with quiet standing and gait,9,43,44 and along with improved strength and flexibility, markedly improves balance and reduces the probability of falling among the elderly.4,45,46

Breathing
Efficient breathing is a central focus of many tai chi training systems, and breath is often directly associated with the concept of cultivation of qi: The inhalation and exhalation are long and deep and the qi sinks to the dan tian (dan tian means cinnabar fields and is located slightly beneath and behind the navel). Many modern tai chi books devote entire sections to breathing techniques.40,47 While tai chi studies to date have not specifically evaluated the therapeutic effects of 1 form of breathing versus another, there is a some evidence that suggests that patterns of breathing, in and of themselves, can make a significant impact on numerous health-related outcomes including metabolic rate, heart rate variability, blood pressure, immunity, and mood.4851 Not surprisingly, tai chi has been shown to increase oxygen uptake and exercise capacity,32 and to improve functional status in conditions with impaired cardiorespiratory physiology including chronic heart disease.52

TAI CHI IS A MULTICOMPONENT COMPLEX INTERVENTION

Regardless of specific style, form, or teaching approach, tai chi itself is inherently a complex intervention, composed of multiple components each of which have potentially independent and synergistic therapeutic value. As such, the study of tai chi may best be viewed as a form of wholesystems research41,42 rather than the study of a single active ingredient. Tai chi is readily described as being composed of 2 (mindbody) or 3 components (mindbodyspirit, mindbodybreath); however, even these hyphenated categorizations are too broad and are themselves composed of multiple components. A more whole-systems or ecologic

Concentration, attention, and mindfulness

The mind component of tai chi includes a number of interrelated aspects that may each confer therapeutic value. One central concept of tai chi is concentration or focus, whereby the mind becomes unified in its purpose for an extended period of time.47 This focused attention can be di-

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FIG. 1. A whole-systems or ecologic characterization of the complexity of tai chi interventions and their purported therapeutic components.

rected to ones own body as well as to the external environment. A typical tai chi phrase that exemplifies this principle is: Cleanse your mind and concentrate on the slowness and evenness of your movements. Experimentally, quantifying the relative therapeutic contribution of concentration/attention versus other components of tai chi may not be feasible, as teaching Tai Chi without concentration/attention would mean it was not true tai chi. However, recent studies have demonstrated that concentration and mindfulness meditation in and of itself (i.e., without overt exercise) has significant neurophysiologic effects, which, in, turn may modulate multiple aspects of health including immune function, mood, and pain.5357 Additionally, studies have shown that long-term tai chi practitioners have greater body awareness (e.g., a kinesthetic sense) compared to nonpractitioners and other athletes.6,58,59

Imagery, visualization, and intention

Another set of mind-related components of tai chi includes imagery, visualization, and intention. Imagery is a

thought process that invokes and uses the senses to serve as a form of communication between perception, emotion, and bodily change.60 Research from fields as diverse as medical placebo and shamanism have demonstrated that our images and beliefs/expectations directly influence our physiology and health.6063 Modern cognitive neuroscience has learned that imagining certain movements activates many of the same brain regions that are engaged during the actual movement.64,65 This observation adds support to a common tai chi saying, imagination becomes reality.66 Tai chi training is typically rich in images or metaphors drawn from the tai chi classics such as: move like a river and stand rooted like a tree, and the names of many tai chi movements themselves (e.g., Cloud Hands, Crane Spreads its Wings) include images that guide students toward certain kinesthetic, emotional, and energetic states. Even more fundamentally, the tai chi classics often emphasize notions derived from the earliest layers of Chinese thought that all movement begins with thought or intention: The mind (yi, intention) leads the qi, and the qi moves the body.35 As with attention and breathing, the therapeutic roles of im-

98 agery and intention per se have not been decoupled from other components in tai chi research, and again, removing these elements would invalidate the training as well as attempts to assess tai chis benefit in clinical trials. However, a growing body of research has clearly demonstrated that the use of active imagery and expectancy has multiple therapeutic effects,62,67 and recent studies have even demonstrated that simply visualizing movements without physically practicing them can improve recovery of motor function following impairment as well as the learning of new complex movements.68,69

WAYNE AND KAPTCHUK Current models of biomedicine, especially in controlled research settings, consider providers as relatively inert vehicles for the transmission of information, despite significant evidence suggesting that variation in health care practitioners attitudes and expectations regarding the effectiveness of an intervention makes an impact on outcomes.63,80 An even greater distinction between tai chi instructors and other health care providers is that tai chi instructors are expected to embody the principles of their art, and it is largely through this embodiment that they transmit the principles (i.e., via visual demonstration of movements, during interactive exercises or form corrections), and more generally, by their overall demeanor. As such, the teacher is far from an inert carrier of information. This richness of the teacherstudent relationship in tai chi challenges the commonly used distinction between specific and nonspecific effects emphasized in placebo-controlled trials.80,81

Physical touch and subtle energy

Different forms of physical stimulation are often integrated into tai chi training. Self-massage before and/or after a tai chi training session is commonly practiced.39,47,70 In the process of form correction, teachers will commonly touch and physically adjust students postures. Even greater physical interactions take place during a 2-person contact exercise such as sensing and pushing hands. In some cases it is believed that interactions, especially those implemented by experienced teachers, include an energetic or healing component. The relative importance of massage and touch in tai chi has not been specifically evaluated, however, a significant body of research suggests that equivalent forms of self- and interpersonal tactile stimulation can have marked physiological and psychological effects.7174 Additionally, the impact of more subtle, energy- or qi-based healing transmission in tai chi is also poorly understood, although some studies are beginning to explore this independently.75 Anthropologists have pointed out that touch in ritual changes how a body feels by altering what it feels.76

Alternative health paradigm and philosophy

As has been described in other complementary and alternative medicine modalities,82 some people are attracted to tai chi because of its holistic health paradigm, philosophy, and spiritual principles.47 Disease and medical conditions viewed through tai chis Traditional Chinese Medicine perspective offer an alternative framework with which to view health and medical conditions. It has been suggested that being provided an alternative medical diagnosis, in and of itself, may result in significant therapeutic effects.83,84 Exposure and adherence to the philosophical and spiritual principles of tai chi, which draw heavily from many Asian traditions including Taoism and Buddhism,40,85 may thus have therapeutic and remoralizing value independent of physical practices. Studies have not compared the effects of tai chi taught with and without an emphasis on philosophy and spirituality, however, medical research has shown that patients with strong spiritual beliefs and faith may live longer and have better health outcomes than people who lack such beliefs.78,86

Psychosocial interactions
Training in tai chi includes significant psychosocial interactions resulting from student interactions with instructors as well as with other students. In some cases, as in many churches, synagogues, and senior centers, tai chi schools can provide a significant source of community-based social support. While we are not aware of studies evaluating the benefits of tai chi learned with (e.g., classes) versus without social support (e.g., videos), social support and identifying oneself as being part of a group has been demonstrated to have therapeutic value for patients with a variety of medical conditions.7779 Some unique characteristics of the teacherstudent relationship in tai chi are worth distinguishing from other therapeutic encounters. One role of the tai chi teacher is to evaluate students exercise performance, and prescribe modifications and new material to facilitate progression. In this capacity, they are similar to physicians and health care providers who diagnose patients, and then prescribe medications or therapies. However, tai chi instructors also commonly play the roles of motivators, coachs, and therapists.

Rituals, icons, and environment

Some aspects of tai chi, like other exercises or activities performed in a repetitive manner, take on the characteristics of a ritual (i.e., the performance of more or less invariant sequences of formal acts . . . not entirely encoded by the performers.).87 Long-term regular practice of the same tai chi forms becomes a daily, almost liturgical act and can represent a journey to a sacred presence. Certain tai chi programs also encourage regular practice regimens and environments (e.g., daily morning practice in nature). Some schools have mandatory rituals such as removing street shoes before entering the training space or saluting to the teacher. For some practitioners, even putting on tai chi slippers has ritualistic qualities. Many training spaces also commonly contain tai chirelated art and symbolic icons,

TAI CHI RESEARCH METHODOLOGIES and play meditative music during classes. Collectively, these rituals, icons, and environmental factors have the potential to create a culturally rich context for meaning, remembering, and perhaps even amplifying certain therapeutic experiences during tai chi practice. Psychosocial factors are underscored as participants accept, and indicate to themselves and to others that they accept the philosophy and symbols . . . encoded in the canon of the entire system.87 The very repetition of a ritual may have a performative efficacy that has a rhetorical, persuasive, or illocutionary effect that works as Klienman and colleagues suggest, even in the absence of significant improvement of physical symptoms.88,89 Through its sensory, polyvalent, presentational, and participatory [envelopment],90 ritual creates a diffusion of self91 that can alter a persons relationship to discomfort and disability. Finally, independent of ritual effects, physical components of many tai chi environments may impact practitioners experiences. While we do not know of studies that have compared the effects of learning tai chi in traditional schools versus other environments (e.g., hospital settings), some health care research indicates that certain environmental characteristic may have therapeutic effects. For example, patients in hospital rooms with unobstructed views of nature or nature art have shorter postoperative stays, use less pain medication, and express higher satisfaction with nursing care than patients with obstructed views.92,93 In summary, tai chi is a multicomponent complex intervention integrating physical, cognitive, social, and environmental factors, all of which may confer some therapeutic effect. Moreover, many of these factors are inseparable and synergistic. This complexity poses a number of challenges to the design and interpretation of clinical trials, which we discuss below and in a companion paper.33

99 specific (e.g., therapistpatient interaction, attention, belief) are integral to tai chi and removing them invalidates the intervention. In this way, tai chi is fraught with the theoretical and practical problems of psychotherapy randomized clinical trial where what are nonspecific effects in drug trials may be characteristic and essential components of the active intervention.94,95 Third, as in other complex systems,81,96,97 components considered specific versus nonspecific may be highly interdependent, and some cannot be independently isolated. For example, if one wished to do a reductionist-type study to evaluate the effects of breathing mechanics on oxygen uptake, even if one believed attention and concentration were not essential to improving breathing, it would be practically impossible to independently evaluate these factors; one cannot ask patients to modify neuromuscular aspects of breathing without them simultaneously shifting more attention and concentration to their breathing. For these reasons, we believe it would be practically impossible to construct a credible, dummy control that mimics the array of active components of tai chi, eliminating the placebo-controlled design as a research tool for tai chi.33

Potential biases associated with randomization

The importance of intention, belief, and expectancy in tai chi, and the implications of these behavioral characteristics to the randomization process also warrant highlighting. As discussed above, one cannot perform valid tai chi without the intention or belief that there will be a positive outcome. In this context, the whole process of randomization, during which patients not interested or invested in doing tai chi might be assigned to a tai chi intervention, could compromise study validity and create bias.42 Randomization should be employed in most controlled studies, because its advantages for minimizing bias for factors other than expectancy and belief are important. When it is used, however, the potential for bias should be acknowledged and measures should be taken to assess expectancy- and beliefrelated characteristics in all study arms. Some supplementary approaches to the randomized controlled research model, including preference designs, are discussed in our companion paper.33

IMPLICATION OF TAI CHIS COMPLEXITY TO ITS EVIDENCE-BASED ASSESSMENT Limitations of placebo-controlled trials and the distinction between specific versus nonspecific effects
One conclusion emerging from the above discussion is that the randomized, placebo-controlled research design in which the efficacy of single, specific active ingredients is studied, while all other co-occurring or contextual factors are (in theory) controlled for and/or considered nonspecific, may not provide a completely valid or practical design for studying tai chi. First, tai chi has multiple potential active ingredients, each with evidence supporting potential therapeutic effects. Second, the traditional concept of a placebo control (i.e., a relatively inert or nonspecific intervention component that can be clearly distinguished from specific components) is challenged by tai chis inherent characteristics. Some factors traditionally viewed as non-

A whole-system ecologic framework for studying tai chi

Tai chis complexity poses more general challenges to simple, single-factor, cause-and-effect reductionist models. For example, the commonly reported reduction in falls following tai chi training probably results from multiple mechanisms including increased leg strength and flexibility, changes in neuromuscular patterning/control, reduced fear of falling, improved body awareness and concentration, and a number of cognitive strategies (e.g., imagining being rooted like a tree).31 Moreover, these factors are likely to interact with one another, change in relative importance over

100 time, and differ for different practitioners. In this sense, tai chi faces many of the challenges encountered in whose systems research, which also (1) emphasizes understanding the therapeutic effects of multicomponent interventions; (2) assumes complex interactions between components, including the effects of patients beliefs and patientpractitioner interactions; and (3) allows for potentially unique responses of individual patients, and patient-specific changes over time in the therapeutic relevance of intervention components.41,42 Consequently, research attempting to understand the mechanisms underlying tai chis therapeutic effects may need to draw on the tools used in disciplines such as epidemiology, sociology, and ecology, which commonly deal with complex, multivariate phenomena.98100 Some promising multivariate analytical tools suggested by whole-systems researchers include path analyses, structural equation modeling, and confirmatory factor analysis.101

WAYNE AND KAPTCHUK

2. Wojtek C-Zao. National Expert Meeting on Qi Gong and Tai Chi Consensus Report. Urbana, IL: University of Illnois at Urbana-Champaign, Nov. 2005. 3. Wolf S, Sattin R, Kutner N, et al. Intense Tai Chi exercise training and fall occurrences in older, transitionally frail adults: A randomized controlled trial. J Am Geriatr Soc 2003;51:16931701. 4. Wolf S, Barnhart H, Kutner N, et al. Reducing frailty and falls in older persons: An investigation of Tai Chi and computerized balance training. J Am Geriatr Soc 1996;44:489497. 5. Wolf S, Coogler C, Xu T. Exploring the basis for Tai Chi Chuan as a therapeutic exercise approach. Arch Phys Med Rehabil 1997;78:886892. 6. Jacobson B, Chen H, Cashel C. The effect of Tai Chi Chuan training on balance, kinesthetic sense, and strength. Percept Mot Skills 1997;84:2733. 7. Hain T, Fuller L, Weil L, Kotsias J. Effects of Tai Chi on balance. Arch Otol Head Neck Surg 1999;125:11911195. 8. Wong A, Lin Y, Chou S, et al. Coordination exercise and postural stability in elderly people: Effect of Tai Chi Chuan. Arch Phys Med Rehabil 2001;82:608612. 9. McGibbon C, Krebs D, Parker S, et al. Tai Chi and vestibular rehabilitation improve vestibulopathic gait via different neuromuscular mechanisms: Preliminary report. BMC Neurol 2005;5:3. 10. McGibbon C, Krebs D, Wolf S, et al. Tai Chi and vestibular rehabilitation effects on gaze and whole-body stability. J Vestib Res 2004;14:467478. 11. Wayne P, Scarborough D, Krebs D, et al. Tai Chi for vestibulopathic balance dysfunction: A case study. Altern Ther Health Med 2005;11:6066. 12. Wu G. Evaluation of the effectiveness of Tai Chi for improving balance and preventing falls in the older population: a review. J Am Geriatr Soc 2002;50:746754. 13. Lan C, Lai J, Chen S, Wong M. Tai Chi Chuan to improve muscular strength and endurance in elderly individuals: A pilot study. Arch Phys Med Rehabil 2000;81:601607. 14. Lan C, Lai J, Wong M. Cardiorespiratory function, flexibility, and body composition among geriatric Tai Chi Chuan practitioners. Arch Phys Med Rehabil 1996;77:612616. 15. Lan C, Lai J, Wong M. 12-month Tai Chi training in the elderly: Its effect on health fitness. Med Sci Sports Exerc 1998;30:345351. 16. Channer K, Barrow D, Barrow R, et al. Changes in haemodynamic parameters following Tai Chi Chuan and aerobic exercise in patients recovering from acute myocardial infarction. Postgrad Med J 1996;72:349351. 17. Lan C, Chen S, Lai J, Wong M. The effect of Tai Chi on cardiorespiratory function in patients with coronary artery bypass surgery. Med Sci Sports Exerc 1999;31:634638. 18. Young D, Appel L, Lee S. The effects of aerobic exercise and Tai Chi on blood pressure in older people: Results of a randomized trial. J Am Geriatr Soc 1999;47:277284. 19. Lai J, Lan C, Wong M, Tenh S. Two-year trends in cardiorespiratory function among older Tai Chi Chuan practitioners and sedentary subjects. J Am Geriatr Soc 1995;43: 12221227. 20. Lai J, Wong M, Lan C. Cardiorespiratory responses of Tai Chi Chuan practitioners and sedentary subjects during cycle ergometry. J Formos Med Assoc 1993;92:894899.

CONCLUSIONS
We conclude that tai chi is best viewed as a complex, multicomponent intervention. The richness and complexity of tai chi, including its integration of physical, cognitive, and ritualistic components, poses challenges to the reductionist (causal) approach of attributing observed outcomes to single, independent, component factors. Moreover, because belief, ritual, and psychosocial interactions are integral components of tai chi, traditional distinctions between specific and nonspecific effects, and reliance on the placebocontrolled design may not be feasible. The study of tai chi shares a number of similarities with the emerging field of whole systems research, and may benefit from the use of its ecologic framework and multivariate analytic tools.

ACKNOWLEDGMENTS
The authors thank Richard Hammerschlag, Ph.D., and Hugh MacPherson, Ph.D., M.B.Ac.C., for helpful comments on an earlier draft of the manuscript of this paper, and Brendan Carney for administrative assistance. This paper was supported by grants 5 U19 AT002022-02, 1 R21 AT00350301A1, and 1 K24 AT004095 from the National Center for Complementary and Alternative Medicine (NCCAM). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NCCAM, or the National Institutes of Health.

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Address reprint requests to: Peter M. Wayne, Ph.D. Tai Chi Research Programs Division for Research and Education in Complementary and Integrative Medical Therapies Harvard Medical School 401 Park Drive, Suite 22A Boston, MA 02215 E-mail: peter_wayne@hms.harvard.edu